Attention deficit hyperactivity disorder

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The Molecular Genetics of ADHD

Molecular genetic studies have already implicated several genes as mediating the susceptibility to ADHD. Researchers have examined candidate genes in dopamine pathways because animal models, theoretical considerations, and the effectiveness of stimulant treatment implicate dopaminergic dysfunction in the pathophysiology of this disorder. Dopamine is a neural trans- mitter in the brain used in both movement control and pleasure reward systems. In its simplest form, the dopamine hypothesis holds that excess clearance of dopamine between neurons may contribute to ADHD. Many studies have focused on the D4 dopamine receptor gene (DRD4) which encodes a protein receptor that mediates the post-synaptic action of dopamine. A meta-analysis of these studies showed a small but statistically significant association, which could not be accounted for by any single study or by publication biases. Although the nature of the mutations in DRD4 have not been conclusively described, a version of the gene...

Adhd And Other Disruptive Behaviour Disorders

Childhood-onset bipolar disorder is frequently associated with or preceded by oppositional defiant disorder, conduct disorder or, more frequently, ADHD 40,48,50,51 . The reasons for the association between bipolar disorder and ADHD remain unresolved. It is presently unclear whether this association is a true comorbidity, or a consequence of a diagnostic overlap between the two disorders, or if ADHD is a prodromal condition in the course of bipolar disorder, or a complication of bipolar disorder. Several studies support the finding that adolescent-onset bipolar disorder shows less comorbidity with disruptive behaviour disorders than prepubertal-onset bipolar disorder 40,48,52 . More recently, ADHD has been found as an antecedent in 50 of patients with prepubertal bipolar disorder, compared to 8.7 of patients with adolescent-onset bipolar disorder 52 , suggesting that ADHD may be an antecedent or an early sign of a very early-onset bipolar disorder. Wozniak et al. 50 interviewed 46...

Attention Deficit Disorder

Among NF practitioners there seems to be nearly universal agreement that this can be a highly effective treatment for many cases of attention deficit hyper-activity disorder (ADHD) in both children and adults. This may be especially true for cases of ADHD that involve cortical underarousal, and a growing body of research using brain imaging techniques such as functional magnetic resonance imaging (fMRI) and QEEG suggests that these may constitute the majority of cases. Relatedly, among the first and still most commonly used NF protocols for attention disorders is one designed to increase cortical activation (b or SMR amplitude) at frontal and or central (e.g., Cz) scalp sites (often with simultaneous training of decreases in 0 or a and 0 amplitude). Joel and Judith Lubar pioneered this protocol, which in its original or slightly modified form continues to be considered highly effective. Some practitioners believe that NF can be effective as the sole treatment procedure, but most...

Elements Of Cbt For Adult Adhd

The elements of CBT that follow will be familiar to any clinician well-versed in the model. What differentiates CBT from being merely a collection of techniques is that, done rightly, it endeavors to enlighten the unique experience of a patient and to help her him explore possibilities for making desired changes. What follows represents a cross-sectional summary of ongoing efforts to modify CBT to the clinical needs of adults with ADHD (see McDermott, 2000 Ramsay & Rostain, in press). Receiving the diagnosis of ADHD is often a liberating experience and offers the first cognitive reframe of a patient's chronic difficulties. To this point, most patients have viewed their difficulties as confirming their maladap-tive core beliefs (e.g., I'm lazy ). Many patients have communicated a sense of relief at finally having a coherent (and nonjudgmental) explanation of their difficulties, hearing that they are not alone in their struggles, and that there is indeed hope for change. The next step...

Empirical Evidence For Cbt For Adhd

Overall, the empirical literature on psychosocial treatments for adults with ADHD is sparse. CBT approaches have offered some encouraging preliminary results. Wilens et al. (1999) performed a chart review of 26 adults seeking treatment for ADHD. Clinical data were collected at baseline, at the point of medication stabilization, and at the end of CBT (introduced after medication stabilization). The findings indicated that CBT was associated with patient improvements on a measure of depression, on clinician ratings of anxiety and improvements on ADHD symptoms, and on a rating of overall functioning, both when comparing the overall effects of the combination of CBT and meds, and when assessing the effects of CBT after medication stabilization. pharmacotherapy and CBT for 45 adults diagnosed with ADHD. Clinical data were gathered at initial assessment and at the end of approximately 16 sessions of CBT. The results indicated that the combined treatment was associated with statistically...

Description Of Cbt Model For Adhd In Adults

The core symptoms of ADHD are developmentally inappropriate levels of impulsivity, inattention, and or hyperactivity that have been present since childhood. To make the diagnosis in adulthood requires clear evidence that these symptoms have caused enduring difficulties throughout the individual's development, although there can be great variability in the intensity of symptoms and in the settings in which they occur. Finally, it must be determined that the symptoms are not better accounted for by another psychiatric or medical condition. The scientific consensus is that ADHD is a developmental disorder with genetic and neurobiological underpinnings. Heritability ratios derived from research of the children with ADHD and their parents and from twin studies of ADHD probands are virtually equivalent to those derived in studies of height among first-degree family members, with an average of 80 of the variance being explained by genetics and only a trifle attributed to shared environmental...

Differential Diagnoses of ADHD in Early Childhood

ADHD in early childhood presents a slightly different and unique differential diagnosis. The conditions to be considered are the following 15. PTSD of infancy. Irritability and attention difficulties are very common in young children who have experienced trauma, yet the origins of PTSD and ADHD are entirely different, so in most cases it is easy to distinguish between the two. At the same time, in complex cases where the young child is chronically exposed to difficult experiences, diagnosis is harder.

The Genetic Epidemiology of ADHD

Family, twin, and adoption studies provide strong support for the idea that genes influence the etiology of ADHD. Family studies find the parents and siblings of ADHD children to have a five-fold increase in the risk for ADHD. Children of ADHD adults have a ten-fold increase in risk, which has led to the idea that persistent cases of ADHD may have a stronger genetic component. Consistent with a genetic theory of ADHD, second-degree relatives (such as cousins) are at increased risk for the disorder but their risk is lower than that seen in first-degree relatives. Family studies have provided evidence for the genetic heterogeneity of ADHD. Studies that systematically assess other psychiatric disorders suggest that ADHD and major depression often occur together in families that ADHD children with conduct and or bipolar disorders might be a distinct familial subtype of ADHD and that ADHD is familially independent from anxiety disorders and learning disabilities. It may therefore be...

Attentiondeficit Hyperactivity Disorder

Initial reports of deficiencies of essential fatty acids among children with attention-deficit hyperactivity disorder and dyslexia raised the promise of potential nondrug treatments. Convincing treatment data from interventional trials has not yet been reported. (Stevens et al. (1995) found that 53 subjects with attention-deficit hyperactivity disorder had significantly lower concentrations of AA, EPA, and DHA in plasma polar phospholipids when compared to 43 control subjects. (Stordy 1995) has described decreased rod function comparing 10 young dyslexics to 10 controls. In an open trial, supplementation with a fish oil containing 480 mg of DHA d for 1 mo improved scotopic vision among these dyslexics. Stordy (2000) has also reported that supplementation with a mixture of essential fatty acids improved motor skills in a open trial of 15 children. Two well-controlled, double-blind placebo-controlled trials among children with attention-deficit hyperactivity disorder supplemented with...

Attention Deficit Hyperactivity Disorder

A role for altered dopamine neurotransmission as the underlying cause of ADHD has been suggested by several observations. First, drugs used to treat ADHD, such as methylphenidate (Ritalin) and amphetamine (Adderal), increase synaptic levels of dopamine in experimental animals and in human subjects. In patients with ADHD, the maximal therapeutic effects of these drugs occur during the absorption phase of the kinetic curve, which parallels the acute release of dopamine into the synaptic cleft. These drugs are said to have paradoxical effects in ADHD children because they cause hyperactivity in normal children but have a calming or cognitive-focusing effect on ADHD children. Second, molecular genetic studies have identified genes that encode proteins involved in dopamine neurotransmission as candidate genes for ADHD. Third, neuroimaging studies have shown reduced activation in the striatum and frontal cortex of ADHD patients that is reversed by the administration of methylphenidate at...

Attention Deficit Disorders All Types

There are multiple studies that have shown QEEG biofeedback to be a successful treatment for attentional problems. These studies are based on the rationale that individuals with attentional problems generally have more slow waves in their EEG than individuals who do not have attentional problems. Therefore, the protocol requires the reduction of slow waves, either theta or alpha, while increasing faster waves, such as SMR or beta. The protocol for EEG biofeedback treatment of ADD ADHD will be presented in the section Case Illustrations.

Example of a QEEG Feedback Protocol for Treatment of Addadhd

One of the applications of QEEG biofeedback is with children who are diagnosed with ADD ADHD. These children have been shown to have more slow waves, such as theta and alpha, and fewer fast waves, such as SMR and beta, in their EEGs than non-ADD ADHD children of comparable age, according to Monastra and colleagues in 1999. The biofeedback technique provides QEEG therapy for ADD ADHD children and trains for a decrease in theta or alpha and an increase in beta or SMR, while simultaneously keeping facial EMG levels at an acceptable level. The specific protocol requires a QEEG assessment to determine which specific bandwidth and microvolt levels will be trained. Several studies have been published that clearly demonstrate that the EEG patterns change according to the direction of training and that clinical improvements are observed with successful training. The number of sessions necessary is usually 40 to 60, depending on how quickly the EEG changes and the amount of behavioral...

Attention Deficithyperactivity Disorder Adhd

ADHD is conceptualized as a disorder affecting several life spheres, including learning and social behaviour. However, in light of its prevalence and characteristics, Koschack et al. 17 and others consider it a trait, and present it as a differentiated style rather than a dysfunction. A comparison between the ICD-10 and the DSM-IV demonstrates the different ways this disorder is perceived and the difficulties involved in understanding it. According to the DSM-IV, ADHD belongs to a group of behavioural disorders, also including ODD and CD. According to this system, children fulfilling the criteria for both ADHD and CD are a separate group with different aetiological, clinical and prognostic characteristics. On the other hand, the ICD-10 identifies the group of hyperkinetic disorders, subdivided into a ''disorder of activity and attention'' and a ''hyperkinetic conduct disorder''. The ICD-10 makes no mention of pure attention deficit disorder, and the basic requirement for the diagnosis...

Fetal Alcohol Syndrome

Undoubtedly, over that period of time countless human fetuses have been exposed in utero to ethanol, but it was less than 30 years ago that P. Lemoine and colleagues in France and K.L. Jones and D.W. Smith in the United States reported the first evidence that ethanol can have deleterious effects on the human fetus. For several years after these authors described the fetal alcohol syndrome there was a tendency to disbelieve that ethanol could cause such dramatic changes in the human fetus. Their description of the syndrome focused on craniofacial malformations and severe neurobehavioral disturbances, including frank mental retardation, as the primary clinical manifestations. In subsequent research it was determined that all fetuses affected by ethanol do not show all features of the syndrome. For example, some may show either craniofacial malformations or CNS effects, but not both. Moreover, sometimes the CNS effects were limited to relatively mild degrees of...

Individual Interventions

Two of the most widely used CBIs are self-instruction training and self-management. The main goal of self-instruction training is to teach children to utilize self-directed speech to guide their own behavior with the assumption that this will lead to improved self-control. Russell Barkley and others have observed that children with ADHD exhibit a developmental lag in developing verbal First, the instructor models self-speech out loud and engages in a task while the child listens and observes. Second, the instructor models self-speech out loud while the child concurrently engages in the activity. Next, the instructor observes and prompts the child when needed while the student uses self-speech out loud and engages in an activity. Then, the instructor observes and eventually discontinues prompting while the child whispers self-speech and engages in a task. The instructor then observes while the child engages in the task silently. From then on, the child is instructed to use private...

Comprehensive Interventions

A number of cognitive-behavioral researchers have developed comprehensive interventions for children and adolescents with ADHD, which include individual skills training, family therapy, and school interventions. To our knowledge, none of these comprehensive intervention packages have been compared in their totality vis- -vis stimulant medications, contingency management, or as an adjunct intervention to the established treatments. Building on the successes and failures of the first generation of CBI for ADHD, Lauren Braswell and Michael Bloomquist (1991) developed one of the most comprehensive treatment packages for children and adolescents with ADHD. This treatment package, Cognitive-Behavioral Therapy with ADHD Children Child, Family and School Interventions, was developed based on an ecological- developmental model of cognitive-behavioral therapy to improve children's self-control. In contrast to previous treatment packages where most of the interventions focused on the child,...

Value to Industry and Research

Attention Deficit Hyperactivity Disorder Attention deficit hyperactivity disorder (ADHD) is a condition characterized by inattention and or impulsivity and hyperactivity that begins in children prior to the age of seven. Their inattention leads to daydreaming, distractibility, and difficulties sustaining effort on a single task for a prolonged period of time. Their impulsivity disrupts classrooms and creates problems with peers, as they blurt out answers, interrupt others, or shift from schoolwork to inappropriate activities. Their hyperactivity is frustrating to those around them and poorly tolerated at school. Children with ADHD show academic underachievement and conduct problems. As they grow older, they are at risk for low self-esteem, poor peer relationships, conflict with parents, delinquency, smoking, and substance abuse.

Course Prevalence and Treatment

Although the longitudinal course of this condition and its prevalence in adulthood have been sources of controversy, a growing literature has documented the persistence of ADHD into adulthood, with about two-thirds of ADHD children continuing to experience impairing symptoms of the disorder though adulthood. Over time, symptoms of hyperactivity and impulsivity are more likely to diminish compared with symptoms of inattention. Prevalence studies from North America, Europe, and Asia show that ADHD affects about 5 percent of the population. The impact of the disorder on society, in terms of financial cost, stress to families, and disruption in schools and workplaces, is enormous. Although current treatments for the disorder are not 100 percent effective, clinical trials have shown that stimulant medications, such as methylphenidate and amphetamine, relieve symptoms and lessen adverse outcomes, while showing few adverse side effects. Because these medicines increase the availability of...

Case Illustrations

Because of the diverse areas of applications of clinical biofeedback, instead of case examples, two general clinical protocols will be presented. The two clinical protocols selected for presentation will be the protocol for biofeedback facilitated relaxation training (BFRT) and for QEEG feedback for ADD ADHD. These protocols reflect the two

Psychiatric and Behavioral Problems

Psychiatric and behavioral problems combined with limited understanding of what is happening to them and an unfamiliar, overstimulating situation often lead to an uncooperative and at times combative child. The prevalence of major psychiatric disorders and attention deficit disorder is two to three times that of the general population. Stereotypy and self-injurious behavior are seen almost exclusively in the mentally retarded population, with increased incidence in children with the most severe cognitive limitations. Treatment of psychiatric and behavioral disorders is similar to treatment of these disorders in the general population.

Treatments Other Than Diet

In considering dietary interventions, it is important to note that there are two other forms of treatment with proven efficacy. These are stimulant medications and behavior modification. Considerations about dietary interventions have to be considered in the context of these other interventions. The nature of the main beneficial treatments, stimulant medication and behavioral interventions, makes the issue of diagnostic criteria for ADHD extremely important. Both of these treatments are not specific for the disorder so that the determination about which children are treated is very dependent on who is diagnosed. Effective behavioral interventions have generally consisted of direct contingency management programs (e.g., point or token programs or a response cost program) and social skills training. Like stimulant medication, these interventions are not specific to ADHD and have no proven long-term benefit when used in isolation. Other approaches, such as traditional psychotherapy and...

Competing Response Practice

Keith was a 12-year-old male who exhibited two motor tics a mouth tic in which he pulled back the corners of his mouth, stretched his mouth open, and stuck out his tongue and an eye-blinking tic involving hard eye blinking. Keith was diagnosed with Tourette's disorder and attention deficit hyperactivity disorder and was receiving sertraline (25 mg) daily. He received competing response training as part of a research project completed by Doug Woods, Ray Miltenberger, and Vicki Lumley in 1996.

The Role Of Inhibition In Cognition And Behavior

Analogous problems can arise in controlling responses that are not reflexes but have become automated through practice. Attention deficit and hyperactivity disorder is a persistent individual difference characterized by an impulsive inability to resist engaging in prepotent or automated actions triggered by task-irrelevant stimuli in the environment or task-irrelevant thoughts in the mind. Intrusion of an unwanted or inappropriate automatic response occasionally occurs in normal children and adults as well. This can be seen in slips of action'' in which distraction of attention while carrying out a low-frequency task can result in inadvertently executing a different task that is higher in frequency given the situation and stimulus environment.

The Risk For Mood Disorders

Studies on the risk for early-onset bipolar disorder in the offspring of bipolar patients are made more difficult by the relative uncertainty of the phenomenology of bipolar disorder in childhood, given the developmental differences of the disorder in prepubertal patients, including atypicality of phenomenology 39 , and the high frequency of comorbidity, mainly with ADHD 40 . More recently a new effort was made to develop diagnostic criteria for different phenotypes of juvenile mania 41,42 , and to produce methodological guidelines, including inclusion and exclusion criteria, for clinical studies in child and adolescent patients with bipolar disorder 43 . Chang et al. 21 described cross-sectional psychopathological features in 60 subjects (mean age 11.1 years) from 37 families with at least one bipolar parent. Of these 60 subjects, 33 (55 ) had a DSM-IV axis I disorder 17 subjects (28 ) met lifetime (but mostly also current) diagnostic criteria for ADHD, 9 (15 ) for major depressive...

Oppositional Defiant Disorder Odd And Conduct Disorder Cd

The age of onset of ODD is early childhood, whereas the age of onset of CD is early adolescence, although it is possible to diagnose it as early as at age 8. There are researchers who see a developmental progression between the two disorders, but this issue remains open to research. The age of onset seems to be earlier in children who also suffer from ADHD 30 .

Behavioral Genetics and Eugenics Contemporary Ethical Concerns

There is no simple response to this issue. One legitimate fear is that the range of social tolerance for personality types and traits will be narrowed excessively to the detriment of such individuals. That is, those individuals may be subjected to excessive social scrutiny and social pressure to conform to a narrow range of socially acceptable behavior. This seems contrary to the core values of a liberal society. However, in other cases medicalization of behavior that once was regarded as normal may be beneficial to both individual and social welfare. Attention deficit hyperactivity disorder (ADHD) illustrates this point. Children who are identified as having ADHD benefit greatly from drugs such as Ritalin. The practical moral problem is that the behavioral and diagnostic boundaries of this disorder are fuzzy and controversial, and this can lead to morally troubling problems of overdiagnosis and underdiagnosis.

Analogue Behavioral Observation

For example, behavioral checklists and behavioral rating scales are the most popular methods of gathering information in assessing ADHD. Narrow band measures include the 55-item Social Skills Rating System, which divides item content into three narrow domains problem behaviors, social skills, and academic competence. Another narrow band instrument is the Disruptive Behavior Rating Scale (DRS). The DRS includes item content covering oppositional defiant disorder, ADHD, and conduct disorder. Broad band behavioral rating scales include the Child Behavior Checklist (CBCL) and the Conners Parent and Teacher Rating Scales. Both the CBCL and the Conners Scales provide several scale scores and include versions for parents, teachers, and youths to complete. The popularity of these behavioral assessment methods can be attributed to their cost-efficiency, ability to quantify the opinions of important persons in a client's life, and their ease of administration. In addition, the most widely used...

Specific Clinical Applications

As noted earlier, training of the amplitude of specific EEG frequencies presently is the most common NF application. This often involves simultaneous training for increasing the amplitude of one frequency and decreasing the amplitude of another. That is, some protocols train for changing amplitude ratios between two frequencies, e.g., lowering the 0 b ratio. Within the general area of frequency amplitude training, there are two often independent groups of NF practitioners (1) those who emphasize training to increase the amplitude of higher (b) frequencies (and, in some protocols, decrease lower frequencies) and (2) those who train increases in the amplitude of lower frequencies (a, 0). The first group, typified by those who treat attention deficit disorder or seek to develop peak performance,'' is interested in developing higher levels of arousal in presumably underaroused (or at least not optimally aroused) cortical areas. This is based on the fact that higher levels of brain...

Miscellaneous Issues

There is some controversy among NF practitioners about which site-frequency combinations should be used for specific syndromes. For example, even in the case of ADHD in which the increase b (or SMR)-decrease 0 band amplitude protocol is used extensively, there are some who argue that decreasing 0 is sufficient or that increasing only SMR (or b) or some narrower band within one or the other of those frequency bands is most efficient and speeds treatment. To the author's knowledge, however, these claims have not been supported by scientific research. An area of some disagreement among practitioners is whether the time of day of NF treatment needs to be matched to the individual client to conform to his or her unique biorhythms. This concern also has been voiced by some in regard to traditional medical treatments and seems worthy of further consideration. The importance of personality characteristics of the NF practitioner also is debated. It seems essential that he or she be empathic,...

Posttraumatic Stress Disorder Ptsd

There are no studies to date estimating prevalence of PTSD in children. Yule's survey 40 presents a number of reports from recent years, according to which the incidence rate in children who underwent a traffic accident is around 20 , while it is about 10-12 in children who were hospitalized as a result of ''common childhood mishaps''. Children who develop PTSD as a result of injury may be the same children who suffer from ADHD or ODD, since children from these populations tend to be more involved in accidents and various injuries.

Major Clinical Syndromes Of Aggression

Frontotemporal dementias Herpes simplex encephalitis Multifocal or poorly localized Attention deficit disorder Several medical conditions that produce aggression have effects on the brain that are diffuse or multifocal. A large body of investigative literature has demonstrated an increased frequency of minimal brain dysfunction and poorly localized neurological soft signs'' in violent patients. In one study, minor and irregularly distributed perceptual, motor, sensory, reflex, and cognitive defects were noted in 119 of 286 patients with a history of recurrent attacks of uncontrollable rage. Minor neurologic findings are common in violent individuals in juvenile reform school and on death row. Attention deficit disorder was significantly correlated with criminal and violent offenses in a prospective study. Not surprisingly, developmental or acute medical conditions producing scattered minor neurological impairments place an individual at higher risk of expressing aggressive impulses....

Empirical Support For Biofeedback

There is increasing evidence that children and adolescents do respond better than adults to biofeedback, at least in the area of headache management. Recent research on biofeedback has continued to empirically evaluate the efficacy of biofeedback treatment for other disorders (e.g., EEG biofeedback for ADHD) as well as compare the efficacy of different modes of biofeedback and potential mediators or mechanisms by which biofeedback may exert its effects (Hermann & Blanchard, 2002).

Assessment Of The Difficult Child

Widely used scales to assess attention-deficit hyperactivity disorder (ADHD) include the Conners Rating Scale 3 and the Swanson, Nolan and Pelham Questionnaire (SNAP-IV) 4 . The Eyberg Child Behavior Inventory 5 is used to evaluate conduct disorder (CD) and oppositional defiant disorder (ODD). Common scales for the assessment of post-traumatic stress disorder (PTSD) are the Children's PTSD Inventory (CPTSDI) 6 , the Trauma Symptom Checklist for Children (TSCC) 7 , the Angie Andy Cartoon Trauma Scale (ACTS) 8 , the Pediatric Emotional Distress Scale (PEDS) 9 , the Clinician-Administered PTSD Scale for Children (CAPS-C) 10 , the Adolescent Dissociative Experience Scale (ADES) 11 , the Children's Perceptual Alteration Scale (CPAS) 12 and the Child Dissociative Checklist (CDC) 13 . The most frequently used rating scale for mood disorders is the Childhood Depression Rating Scale - Revised (CDRS-R) 14 , which is a modified version of the Hamilton Depression Rating Scale. The continuous...

Differential Diagnosis And Comorbidity

Bipolar youths exhibit significantly higher rates of comorbid psychiatric conditions, including disruptive behaviour disorders (especially ADHD, conduct disorder and oppositional defiant disorder), anxiety disorders (especially separation anxiety and panic disorder) and eating disorders. The relationship between ADHD and mania is of interest. A very high comor-bidity between paediatric bipolar disorder and ADHD has been reported. As many as 60-90 of the paediatric bipolar disorder cases have been diagnosed with concurrent ADHD 55,56,48 . Careful assessment is needed to clarify whether children have ADHD, bipolar disorder or both. There is an overlap of symptoms between mania and ADHD. These symptoms include increased motor activity, distractibility, rapid or pressured speech, impaired attention, racing thoughts and irritability. Geller et al. 42 have suggested that ADHD is an age-dependent manifestation of bipolar disorder, as normal pre-pubertal children are more hyperactive than...

Behavioral Observation 1 Naturalistic Behavioral Observation

Children diagnosed with attention deficit-hyperactivity disorder (ADHD) in their classrooms and systematically varied each child's daily dose of methylphenidate (MPH). By observing multiple, operationally specific behaviors over time (e.g., social behavior, disruptive behavior,

Hyperactivity and Antisocial Behavior

In children, there is an increasing frequency of the diagnosis of ADHD, a condition characterized by inattention, impulsive and disruptive behavior, learning difficulties, and increased levels of gross motor activity and fidgeting. Also, the prevalence of food allergies and intolerances has been increasing. Perhaps it is not surprising that dietary explanations and treatments for ADHD have been sought regularly for several decades, given theories of allergic reactions or intolerance to food additives, ingredients in chocolate, and even refined sugar (often grouped as the 'Feingold theory', after an early instigator of unproven dietary intervention). There has also been a long-standing interest in the possibility that antisocial behavior in children and adults might in part result from poor nutrition, although early studies were poorly designed. Behavioral effects of sugar and of many additives have by and large not been supported by controlled studies however, determining...

Impact Of Catecholamines On Behavior

Much of the information that is available concerning the functions of catecholamines in regulating human behavior directly results from the use of a group of medications often called psychotropic drugs and antidepressant medications called thymoleptics. Other medications that impact on catecholamines include psychostimulants, such as dextroamphetamine and methylphenidate (commonly known by its trade name, Ritalin) and l-dopa (which has been used to treat Parkinsonism), as well as a medication that was initially used to treat hypertension. Most of these drugs affect more than one system (e.g., dopaminergic, noradrenergic, or serotonergic systems). Catechola-mines have been proposed as mediators of many psychiatric illnesses, including schizophrenia, Tour-ette's syndrome, depression, autism, attention deficit-hyperactivity disorder, stereotypic movements, tremors, and substance abuse. More generically, cate-cholamines also play a critical role in the stress response. Unfortunately,...

Historical Notes A Early Beginnings

A major turning point for NF came in the late 1980s largely due to several nearly simultaneous events publications by Joel and Judith Lubar detailing successful treatment of attention deficit disorder with EEG biofeedback, a research publication by Eugene Peniston and Paul Kulkosky, and the development of high-quality, relatively low priced equipment for both QEEG evaluation and EEG biofeedback by companies such as Lexicor Medical Technology of Boulder,

The Nullification of the Supply and Demand Relationship

When the American Psychiatric Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM), changed the definitions in DSM IV of attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD), it quadrupled the number of patients, especially children and adolescents, who would be eligible for treatment. The widespread medication of children and adolescents with psychotropic stimulant drugs now includes increasing numbers of preschool children, prompting two White House Conferences on the subject in the year 2000.

Dopamine And Neuropsychiatric Disorders

Many lines of evidence suggest a role for dopamine in neuropsychiatric disorders such as PD, schizophrenia, attention deficit hyperactivity disorder (ADHD), and drug abuse. The first evidence for dopamine's involvement in these disorders came from either postmortem histological neurochemical studies or the observation that the drugs used to treat these disorders either increased or blocked dopamine neurotransmission in the brain. Since the advent of neuroimaging techniques such as positron emission topography (PET), a majority of the current human studies use this technique to further define the role of dopamine in these disorders.

Dopamine Related Genes

The expression of the dopamine D4 receptor (DRD4) gene in the anterior cingulate cortex is of particular interest. As reviewed by Williams and Rakic from Yale University, the anterior cingulate cortex contains high levels of DA innervation in layers II-VI. Dopaminergic axonal fibers arising from the VTA form axon-axononal connections and allow large regions of this cortical area to be globally regulated. The cingulate cortex contains interneuron populations expressing dopamine D2 receptor (DRD2) and DRD4 receptors and pyramidal neurons expressing dopamine D1 receptor (DRD1) receptors. Whereas most DA receptors are expressed widely throughout the brain, DRD4 shows its highest levels of expression in the frontal and cingulate areas. Interestingly, a polymorphism in the cytoplasmic loop of the DRD4 gene has been associated with attention deficit hyperactivity disorder. Similarly, a specific polymorphism of the dopamine D3 receptor (DRD3) and DRD2 genes was associated with schizophrenia,...

Pervasive Developmental Disorders PDD

The differentiation between pervasive developmental disorders (PDD) and ADHD may appear obvious. However, many children who have these disorders in various degrees of severity also exhibit symptoms of ADHD and even respond well to psychostimulants. This is especially true of Asperger's syndrome, which is more elusive from a diagnostic point of view than the other syndromes belonging to this group. Since the main characteristics of Asperger's syndrome include severe and persistent disturbances in social interactions and development of limited and repetitive behavioural patterns, interests and activities, these children show a significant clinical impairment in important functional areas such as the social or occupational sphere. An example of the confusion in this area is given by the work of Ghaziuddin et al. 57 , which describes comorbidities of Asperger's syndrome and shows that the most common comorbidity in these children is that with ADHD. A study that examined the development of...

Total Cerebral Volume

Autism, attention deficit hyperactivity disorder (ADHD), childhood-onset schizophrenia, dyslexia, eating disorders, fetal alcohol syndrome, obsessive-compulsive disorder, Sydenham's chorea, and Tourette's syndrome. It is evident that a normative sample must be carefully screened to rule out these conditions. Likewise, affective disorders and substance abuse have been associated with structural anomalies in adults and should be considered as potential confounds in pediatric samples as well. Beginning with Geschwind, several investigators have noted a relationship between handedness and structural symmetry measures of the brain. Handedness should not be viewed as strictly left or right but as a continuum, and it should be quantified as such. Patient and control groups must be matched for handedness since symmetry differences are often key features in discriminating groups such as ADHD, dyslexia, or Tourette's disorder.

Christine Maguth Nezu and Michelle A Peacock

In 2000 (Rush & Frances, 2000), practical clinical guidelines based on expert consensus and relevant research for treating persons with mental retardation suffering from major mental disorders were developed to assist clinicians in treatment decision making. Applied behavior analysis, managing the environment, and client and family education were the most highly recommended psychosocial treatments for many disorders including autism, attention-deficit hyperactivity disorder, conduct disorder, substance abuse and substance dependence, as well as target symptoms such as self-injurious behavior, aggression, and pica. CBT (e.g., anger management, assertiveness training, conflict resolution) was recommended as a first-line option for major depressive disorder, posttraumatic stress disorder, obsessive-compulsive disorder, and symptoms of anxiety. CBT was also recommended as a second-line option for bipolar disorder (manic phase), schizophrenia and other psychotic disorders, generalized...

Neuropsychological Testing

The clinical neuropsychological evaluation of patients with possible toxic encephalopathy necessitates that the clinician perform a careful and thorough examination of each patient. Many areas of cognitive function must be assessed so that exposure-related effects can be detected and other possible diagnoses comprehensively evaluated and ruled in or out. Because there is overlap between the behavioral effects of exposure to certain neurotoxic chemicals and those associated with developmental disorders (e.g., learning disabilities, attention deficit disorder), psychiatric conditions (e.g., posttraumatic stress disorder, bipolar disorder), neurological diseases (e.g., multiple sclerosis, cerebrovascular disease, primary progressive dementia, parkinsonism), and the exposure to ethanol, medications, and illegal drugs, the test battery must allow for consideration of these alternative or contributing conditions.

Using Neurofeedback to Change Attentional States

Following the early work on seizures, Joel Lubar and others began to work on a neurofeedback application to help improve the attentional abilities of children and adults with attention deficit disorder (ADD or ADHD). A great deal of research has indicated that ADD is often accompanied by an excess of slow brain waves, especially during less compelling tasks such as

Differences Between Adult Adolescent And Childonset Bipolar Disorder

A few published studies have investigated the differences between child-onset and adolescent-onset bipolar disorder. Faraone et al. 50 recruited 68 children (12 years old or younger) and 42 adolescents (older than 13 years) who were hospitalized and met criteria for mania. Comparison groups were 527 non-manic referrals and 100 normal controls. With the exception of comorbidity with ADHD, there were more similarities than differences between the children and adolescents with mania. There was an inverse relationship between the rate of comorbidity with ADHD and age of onset of mania, i.e. higher in manic children, intermediate in adolescents with childhood-onset mania, and lower in adolescents with adolescent-onset mania. The authors concluded ADHD was more common in childhood-onset compared with adolescent-onset bipolar disorder and suggested ADHD may signal a very early onset of bipolar disorder in some cases.

Indications for and Limitations of CBT for Treating Childhood PTSD

Children, some trauma-focused CBTs also have proven equally effective at diminishing peripheral psychopathology, including depression and anxiety (March et al., 1998). This is an important finding as many children with PTSD may have comorbid conditions, commonly including depression, anxiety, and attention-deficit hyperactivity disorder.

Empirical Support For Cbt With Children

CBT for externalizing disorders have resulted in less consistent results. For example, CBT for ADHD has been found to be less effective than medication (e.g., MTA, 1999). However, CBT for aggression and conduct-related problems (e.g., Kazdin, 2002 Lochman, 1990 Lochman, Whidby, & FitzGerald, 2000) may be effective in reducing aggressive behavior and increasing prosocial behavior. Unfortunately, it is not clear that gains can be maintained over time and generalized to other situations.

Pharmacogenetics and psychopharmacology

Genetics of attention deficit hyperactivity disorder (ADHD) ADHD is the most common psychiatric disorder with onset in childhood. The condition is characterized by inattention and or hyperactivity and ADHD is a familial disorder with a population-based prevalence of about 10 and a prevalence rate in siblings of approximately 25 . Detailed studies of the disorder suggest that there is a five- to sixfold increase in first-degree relatives of affected persons. However, as with other psychiatric disorders, the finding of familial aggregation alone does not necessarily lead to the conclusion that the disorder is of genetic origin as such studies do not separate genetic from environmental factors. Twin studies have been useful in discriminating the genetic from environmental factors. The concordance rate for monozygotic versus dizygotic twins has been estimated at 51 and 33 respectively, and it has been estimated that approximately half the variance in the trait factors of hyperactivity and...

Temperament And Bipolar Vulnerability

Studies of offspring at risk for bipolar disorder have found mood and behavioural difficulties suggestive of an affective dysregulation. A study considering seven 2-year-old sons of bipolar mothers found significant aggressive behaviours during laboratory observations, compared to control offspring of nonaffected mothers 79 . Chang et al. 26 addressed this topic in a sample of 53 children and adolescents of bipolar parents, 27 of whom (52 ) received a psychiatric diagnosis (28 ADHD, 15.1 anxiety disorder, 13.2 bipolar disorder and 11.3 depression), and were evaluated with a temperament measure 80 . The bipolar offspring as a whole showed lower scores in the general activity scale and higher scores in the approach and rhythm-sleep scales. Bipolar offspring with psychiatric diagnoses showed higher activity levels than bipolar offspring without diagnoses, and lower scores on flexibility, positive mood and task orientation. Grigoroiu-Serbanescu et al. 16 found that bipolar offspring with...

Predictors Of Psychopathology

Duffy et al. 54 explored whether some significant symptoms of inattention were present among the 53 offspring of 30 bipolar patients, with (n 24) or without (n 29) psychopathologies (mostly in the mood and or anxiety domain). A lack of evidence of premorbid ADHD and an absence of current attentional problems was found with an objective measure (a cancellation test), even though with a subjective measure (a self-administered ADHD rating scale) a significant difference was found between the well and psychiatrically ill, as well as between those with and those without an affective disorder. This led to the hypothesis that attentional difficulties may reflect the activity of the underlying mental disorder rather than a real attentional problem, and caution against a possible overdiagnosis of ADHD in the presence of another Axis I disorder. A dimensional approach can help to define behavioural and emotional profiles in children and adolescents of bipolar parents, capturing earlier...

Basic Tenets And Philosophy

Therapy were found to be effective in the treatment of atten-tion-deficit hyperactivity disorder, encopresis, enuresis, obesity, obsessive-compulsive disorder, recurrent headache, and the undesirable behaviors (e.g., self-injury) associated with pervasive developmental disorders. A growing body of research is addressing the mechanisms of change in these therapies as well as questions about the applicability of these treatments to a variety of clinical settings and populations (i.e., the moderators of change).

Clinical Description

NF1 usually presents with pigmentary features. Multiple cafe-au-lait macules begin in early childhood, and skin-fold freckles appear between 3 and 5 years of age. 2 Iris Lisch nodules are melanocytic hamartomas that are useful in diagnosis but are clinically silent. 3 Other common nontumor manifestations include skeletal dys-plasia, macrocephaly, vascular dysplasia, and learning disabilities. Skeletal dysplasia most often affects long bones, particularly the tibia. 4 Tibial dysplasia presents in infancy and creates risk of fracture. Orbital dysplasia occurs in association with trigeminal plexiform neurofi-broma. Children with NF1 tend to be short and have relative or absolute macrocephaly. 5 Vascular dysplasia consists of nodular proliferation within the arterial wall and may cause arterial stenosis or hemorrhage due to dissection. 6 Learning disabilities occur in at least 50 of affected individuals and include both verbal and nonverbal problems. 7 There may also be attention deficit...

Legislation and Governmental Recognition

In retrospect the whole idea of 'categories of handicap' seems problematic. In some cases, certainly, children could be said to have one particular handicap in other cases, however, there were overlapping handicaps. In the last two decades there has been greater recognition of dyspraxia (clumsy child syndrome) and of ADHD (attention deficit hyperactivity disorder). In some cases there is co-morbidity with dyslexia in some cases not. We owe to the Warnock Report a wider public recognition that children cannot always be fitted into pre-specified categories there are all kinds of overlap.

Disorders Involving Educational Behavioral Intervention

Attention Deficit Hyperactivity Disorder Attention deficit hyperactivity disorder (ADHD) represents a manifestation of neuropsychological disorders estimated to occur in approximately 5 (or more, depending on source) of school-aged children. Boys are referred approximately 3-4 times more frequently than girls. Neuropsychological assessment is indicated for determining the exact nature of the disorder (1) classic (hyperactive, restless, distractible) (2) inattentive (absent-mindedness without hyperactivity) and (3) temporal lobe (aggressive, memory problems). Whereas SPECT imaging can document the physiological basis of these types of ADHD, neuropsychological assessment is method of choice for documenting the presence and type of disorder and recommended intervention approaches.

Complex Behaviors Complex Causes

Thus, for use and abuse of alcohol, we know that the importance of genetic and environmental effects changes with sequencing in the use and abuse of alcohol, from abstinence or initiation to frequency of regular consumption, to problems associated with consumption, and ultimately, to diagnosed alcoholism and end-organ damage from the cumulative effects of alcohol. Similar stories could be told for many other behaviors of interest. Thus, for the major psychopathologies, from depression and schizophrenia in adults to attention deficit disorder in children or eating disorders in adolescents, genetic influences are invariably part of the story but never the whole story.

Pharmacological Treatment

The largest systematic treatment trial to date was a recent study conducted by Kafantaris et al. 91 . This study examined the initial response to lithium treatment and potential predictors of non-response in a sample of 100 acutely manic bipolar I adolescents 63 met response criteria and 26 achieved remission of manic symptoms at the week 4 assessment. Prominent depressive features, age at first mood episode, severity of mania and comorbidity with ADHD did not distinguish responders from non-responders. When treated with adjunctive antipsychotic medication, subjects with psychotic features at baseline responded as well as subjects without psychosis. In this study, lithium appeared effective for acute stabilization of bipolar symptoms. However, more double-blind, placebo-controlled trials in adolescents with acute mania are needed. Frazier et al. 112 used risperidone in 28 youth (mean 10.4 years old) with bipolar disorder (25 mixed and 3 hypomanic). These children received a mean dose...

Use of psychotropic drugs in specific childhood disorders

Attention deficit hyperactivity disorder (ADHD) This is a heterogeneous disorder of inattention, hyperactivity and impulsivity that starts in childhood and may persist into adulthood. Children with the disorder can be identified by their inattention which leads to daydreaming, distractability and difficulty in sustaining an effort to complete a task. Their impulsivity makes them accident prone and disruptive while their hyperactivity, combined with excessive talking, is poorly tolerated particularly in schools. As teenagers, the hyperactivity and impulsivity tend to diminish but other symptoms persist. The adolescent with ADHD often has low self-esteem, poor relationships with peers and often becomes subject to drug abuse. To what extent ADHD persists into adulthood is open to debate, but some longitudinal, family and genetic studies would favour this view. ADHD is often co-morbid with conduct, depressive, bipolar and anxiety disorders. Psychopathology of ADHD Evidence of...

Possible Implications Of Observations In Rat In Human Behavior

Attention-deficit hyperactive disorder (ADHD) is known to be typical among atopic patients (Stevens, 1995, 1996). Atopic dermatitis is treated effectively with steroidal anti-inflammatory drugs and other antiallergic drugs that exert their effects mainly by inhibiting the cascade of LA ARA lipid mediators of allergic, inflammatory reactions receptors (LA cascade). Clinically, decreasing the intake of LA and increasing the intake of n-3 fatty acids that are competitive effectors of the LA cascade and partial agonists for the lipid mediator receptors were shown to be effective for the prevention of atopic dermatitis (Kato, 2000) and other allergic hyperreactivities (Ashida, 1997). In rodents suffering from n-3 fatty acid deficiency, the observed decrease in the feedback suppression of negative responses in the brightness-discrimination learning test (Fig. 3) and the increase in anxiety in the elevated plus-maze test (Nakashima, 1993) appear to have characteristics common to ADHD in...

An Integrativedynamic Model Of The Difficult Child

The development of the ''difficult'' child is based on an organic nucleus that is in constant interaction with other characteristics of the person carrying it. In addition, and important to the same degree, is the interaction that develops between the child and his her environment, starting with his her parents and ending with large social systems. These interactions determine the development of the difficult child's characteristics, and in fact constitute a central factor in formulating the diagnosis, whether it is ADHD, ODD CD or PTSD. Not surprisingly, in light of the complexity of these processes, it may be expected that there will be multiple diagnoses. In fact, these diagnoses are only descriptive that is, they describe symptoms, and their developmental process is common in more fundamental ways. In addition, since frequently there is a common aetiological source, the same child is likely to be diagnosed differently at different stages in his her development. Here dynamism, the...

Diagnostic Assessment

Clinical rating scales may be helpful in tracking the severity and course of target symptoms of mania. Such rating scales for bipolar disorder used to be underdeveloped and understudied, but at the present time several investigators are looking into the usefulness of various scales. Strober et al. 36 used the Beigel-Murphy Scale 73 in assessing severity of mania in adolescents and reported the instrument to be helpful. Fristad et al. 74 modified the Mania Rating Scale 75 for use in pre-pubertal manic children. A preliminary study found that it was helpful in differentiating manic children from hyperactive children 76 . The Child Behavior Checklist (CBCL) has been reported to distinguish children with mania from those with ADHD 70,77 . Such rating scales can be used to supplement clinical evaluation.

Differential Diagnosis Childhoodonset Psychosis

The clinical picture of childhood-onset psychosis may include a tendency towards isolation and becoming reserved and withdrawn, but also soft neurological signs, delayed language development and attention deficit. These features, which might be characteristic of children who suffer from ADHD, do sometimes cause diagnostic confusion. They raise the question of whether a child who was diagnosed with ADHD and later with schizophrenia suffered from the outset from early signs of the latter disorder. This question is important, since the traditional treatment for ADHD, i.e. psychostimulants, conflicts with the common treatment for schizophrenia, and there are those who assert that it might even increase the risk of developing the symptoms of the latter disorder. In a recent study, ADHD was diagnosed in 31 of first-degree relatives of schizophrenic patients, Children suffering from ODD are also likely to camouflage signs of childhood psychosis. Impaired judgement of reality and cognitive...

Relationships Between Disease States and Neurotransmitter Transporters

Contribute to the etiology of multiple neurobiological diseases. Indeed, many studies have suggested for years, largely on the basis of pharmacology, that the monoamine transporters NET, DAT, and SERT play an important role in regulating mood, learning, and motor activity, while GABA transporters have been implicated in neuronal excitability dysfunction such as epilepsy. Indeed, a decade of innovative pharmacology resulted in the development of compounds that, by targeting neurotransmitter transporters, alleviate the symptoms of neurological diseases such as drug abuse and attention deficit hyperactivity disorder. New hopes for the cure of these conditions are coming from studying the gene organization and polymorphisms of these membrane proteins. It has been shown that variations in the human neurotransmitter transporter sequences, known as polymorphisms, may alter transporter expression level, activity, or regulation that ultimately may influence the levels of extracellular...

The Persistence of Time

FIGURE 1 Peak-interval procedure Percent maximum response rate plotted as a function of signal duration for a single adult participant (ALB) diagnosed with attention deficit disorder (ADD) trained at two criterion times (7s and 17s) under two conditions of intertrial interval (ITI) feedback (25 and 100 ). The top panel shows performance at these two criterion times under the two ITI feedback conditions in an unmedicated state (NicPre) and the bottom panel shows performance in a medicated state (NicPost). See Levin et al. (1996, 1998) for additional procedural details. FIGURE 1 Peak-interval procedure Percent maximum response rate plotted as a function of signal duration for a single adult participant (ALB) diagnosed with attention deficit disorder (ADD) trained at two criterion times (7s and 17s) under two conditions of intertrial interval (ITI) feedback (25 and 100 ). The top panel shows performance at these two criterion times under the two ITI feedback conditions in an unmedicated...

Neuropsychology Defined

Functioning can be seen in a number of varied settings with respect to physical and organizational aspects. Impaired functioning may be relatively obvious in terms of a stroke victim or relatively subtle in terms of a child with attention deficit disorder syndrome. The range of settings in which disordered brain functioning may cause behavioral disturbances can encompass a private practice setting, an educational setting, an industrial or occupational setting, a substance abuse treatment facility, a rehabilitation setting a neurology or psychiatry ward in a major teaching hospital or in a community hospital. In all of these settings, or impaired brain functioning may cause disturbances that are responsible for specific problems in terms of adapting to the behavioral demands of the setting. The sorts of problems that the biological insult causes may be related to cognitive skills, sensory-perceptual abilities, motor skills, or emotional personality functioning. This may have...

Training Requirements

Few states regulate the practice of NF, yet it is being used with clients with a wide range of medical and psychological conditions. Many both inside and outside the field express alarm about potential dangers to the public when practitioners with minimal or no training in neurology or neuropsychology, or even general medicine or psychology, are treating persons with ADHD, depression, brain injury, and other conditions.

Programming Adult Neurological Disease Parkinsons Disease

Dopaminergic nigral neurons produced that survive to maturity, and the lifespan of those that do mature, may be compromised by an adverse in utero environment during dopaminergic neurogenesis that alters the time of onset, effectiveness or availability of trophic factors and or transcription factors.106 For example, it is known that an excess of retinoic acid (part of the Vitamin A molecule) inhibits the transcriptional activity of Nurrl and is teratogenic. Nurrl is thought to play a key role in differentiation, maturation and maintenance of brain dopaminergic neurons and neural circuits.107 There is also evidence that it has an instructive role in dopamine synthesis and storage in the adult brain.108 In rats exposed prenatally to excess retinoic acid between gestational days 14-16, cerebellar weight was reduced and the cluster of behavioural and motor effects was consistent with disturbance in the mesolimbic dopamine system.109 Disturbances of the development of the dopaminergic...

Genetics And Evolution

As described, the anterior cingulate cortex has been implicated in a number of psychiatric disorders. Interestingly, all of these disorders show familial patterns of inheritance, increased risk among first degree relatives of affected patients, and increased concordance in identical vs fraternal twins. The heritability (see Glossary) has been estimated for schizophrenia (0.6), attention deficit hyperactivity disorder (0.79), obsessive-compulsive disorder (0.68), and major depression disorder (0.6). Estimates of heritability have been extended to specific cognitive functions in normal populations as well. Tasks that activate the anterior cingulate cortex, such as spatial working memory, divided attention, and attentional set shifting, have been examined in identical and fraternal twin populations and have high heritabilities. These findings suggest that genetic factors play a role in behaviors associated with anterior cingulate abnormalities and normal anterior cingulate function....

Psychiatric Disorders

Other psychiatric disorders that have been associated with abnormal functioning of the anterior cingulate cortex include attention deficit hyperactivity disorder (ADHD) and schizophrenia. These patients show reduced activity in portions of the anterior cingulate cortex, particularly in caudal regions. Both attention deficit hyperactivity disorder and schizophrenia have been linked with poor dopaminergic modulation of prefrontal circuitry. Given the strong dopaminergic projections to the anterior cingulate cortex, these findings are consistent with a disruption in the modulation of anterior cingulate activity. Finally, individuals with psychopathic or sociopathic behaviors show less activity in the anterior cingulate cortex following errors in performance than do individuals without these characteristics, as evidenced in the ERN literature. This finding is consistent with the cingulate epilepsy literature mentioned previously.


The methods presently used in most clinical QEEG biofeedback applications are based on determining which frequency or bandwidth is of interest and then providing the individual with information about its activity either via a shift in frequency or amplitude. There are other techniques used to provide information about the EEG, such as hemisphere asymmetries and average evoked potentials, but their use, at this time, is not as widespread as amplitude or frequency-based applications. The clinical protocol for QEEG feedback for the treatment of attention deficit disorder attention deficit - hyperactivity disorder (ADD ADHD) will be presented later in the section Case Illustrations.

Clinical Descriptions

Many investigators contend that irritability or prolonged aggressive temper outbursts rather than euphoria are the hallmarks of the disorder in children and adolescents 39 . However, episodic irritability can also be seen in depressed children and chronic irritability is common in attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder and some variants of pervasive developmental disorder. Other investigators have suggested the episodic decreased need for sleep being a hallmark of bipolar disorder. Of all the symptoms of mania, decreased need for sleep is the one that has been shown to have pathophysiological significance 40,41 . Decreased need for sleep characteristic of mania should be distinguished from nonspecific insomnia (which is generally accompanied by feeling tired) or chronically decreased need for sleep that may be seen in ADHD. Also, stimulant-induced insomnia (generally early insomnia) needs to be ruled out. as a high degree of comorbidity. In...

Virtual Reality in Rehabilitation

Physical rehabilitation has obvious VR applications, but VR can also reach people with specific attention and movement disorders. Paradoxical walking or the diminished ability to walk voluntarily is a condition suffered by patients with Parkinson's disease. The difficulty of walking can be overcome if only stationary objects can be placed along the walk paths. VEs can be used in presenting the virtual images to the nondominant eye and scrolling the objects toward the subject along a virtual ground plane. Perception of the objects stabilizes appropriately as the subject walks over them. The VE can create images of such stationary objects with the use of special glasses and can superimpose these images onto the real environment, enabling people with paradoxical walking disorder to walk again (Weghorst, 1997). Attention deficit disorder and visual impairments are other domains in which VR rehabilitation is believed to be effective as the VR provides users with visual cues of objects in...

Computer Based

Captain's Log software, available through BrainTrain, and the training exercises developed by Bracey are examples of other computer-based cognitive training packages that include tasks intended to improve auditory and visual attention. There are a number of software exercises available through different vendors, all designed to improve attention, in head-injured or ADHD populations. Although there is no software designed specifically for use by psychiatric populations, some success has been reported in the application of the exercises to this patient group. Psychiatric patients often have severe motivational problems that can affect response to any treatment. Characteristics of software that are best suited to populations with motivational problems include engaging presentation of material, options for personalizing and controlling aspects of the task, frequent feedback, and placing the activity in appealing, relevant contexts. Educational software, developed for use in primary and...

Cory F Newman

Unipolar depression, but also involving varying degrees of euphoria, impulsivity, irritability, hyperactivity, agitation, and (sometimes) psychotic ideation. Less prevalent than unipolar depression, it strikes 0.8-1.6 of the adult population. Less is known about the incidence in childhood and adolescence, as the field is still trying to disentangle and otherwise understand the relationship between early onset bipolar disorder and childhood disorders such as conduct disorder (CD) and atten-tion-deficit hyperactivity disorder (ADHD). Bipolar illness appears to be represented equivalently between the genders, and across ethnic groups (Bauer & McBride, 1996).

Case Illustration

To describe the elements of behavioral consultation, we will consider the hypothetical, somewhat ideal case of Jimmy. Jimmy is a third grade student. His teacher, Ms. Thompson, has reported that Jimmy often acts out in class and that his behavior is disruptive to other students. Jimmy often spends so much time acting out that he completes very little of his work. She believes that Jimmy has attention deficit hyperactivity disorder (ADHD), and has asked the school psychologist what can be done about Jimmy's behavior. It is important to note what has not been addressed through the consultation process. Ms. Thompson's initial impression, that Jimmy suffers from ADHD, was not addressed because a short list of only two specific related behavior problems (nonengaged behavior and failure to complete work) was generated. These behaviors were adequately treated through the problem-centered consultation process, and Ms. Thompson reports no other concerns about Jimmy. Thus, there seems to be no...


DARPP-32 (dopamine and cyclic adenosine 3',5'-mono-phosphate-regulated phosphoprotein, 32 kDa) is a specific inhibitor of PP1. It is expressed at high concentrations in medium spiny neurons of the neostriatum where it plays a central role in integrating responses to dopamine (acting via the cAMP) and glutamate (acting via Ca2+) in dopaminoceptive neurons (Figure 3, right). Diseases associated with defects in dopaminergic neurotransmission include Parkinson's disease, Huntington's disease, ADHD, and schizophrenia.

Diagnostic Issues

Hyperactivity, or ADHD, is a condition that has been recognized for many years and has been quite extensively researched, but the diagnostic criteria and treatment continue to be controversial. The symptoms of ADHD were first described by a German physician, Heinrich Hoffman, in a children's book written in 1848. The symptoms were represented by two children, Harry, who looks in the air (inattention), and Fidgety Phil (hyperactivity). In 1902, George Still presented a lecture in England about 20 children who were aggressive, defiant, excessively emotional and lacking inhibitory volition, and who were also noted to have impaired attention and over-activity. A more etiological conceptualization of the condition did not occur until after World War I. In 1980, the US characterization of inattention and hyperactivity was changed in several ways. It was conceptually defined by three symptom dimensions inattention, impulsiveness, and hyperactivity, with inattention playing a more prominent...

Sugar Restriction

Sugar restriction has been studied as a treatment for children since 1982. There have been a total of 23 appropriate objective studies contained within 16 reports employing a wide variety of types of children, including children with ADHD and aggression as well as normal children, and varying in age from preschool children to adolescents. All of the studies with two exceptions were challenge crossover studies in which children were challenged with drinks containing either sugar (sucrose in most studies) or an artificial sweetener (mostly aspartame). The other two studies consisted of giving the children diets that were high in sucrose content or low in sucrose and sweetened with aspartame or saccharin. A meta-analysis of the 23 studies did not find any significant behavioral or

Feingold Diet

The Feingold diet restricts foods with dyes, preservatives, and salicylate compounds. Investigations of this diet, which were reviewed in 1986, generally involved children with ADHD. In most of the studies the children were kept on an additive-free diet and then challenged with a food containing an additive or an additive-free food as placebo. Two studies used additive-containing and additive-free diets. A problem in comparing studies was the variation in type and dose of additives used. There were a total of 13 controlled studies. The summation of the findings found little, if any, effect. At best, there was some suggestion that a small percentage of children (1 ) were adversely affected by additives. However, a recent study found that 24 of 34 children referred for hyperactiv-ity (no formal diagnosis was established) who responded in an open clinical trial to an additivefree diet responded adversely to challenges with varying doses of tartrazine compared with placebo, whereas all...

European Views

A recent study 22 was carried out in 140 adolescent offspring, aged 12-21 years, of bipolar parents living in the Netherlands, 41 of whom (29 ) met diagnostic criteria for at least one current DSM-IV mental disorder. The most frequent diagnoses were mood disorder (14 , including 3 with a bipolar disorder), anxiety disorder (8 ), substance use disorder (6 ), ADHD (4 ) and disruptive behaviour disorder (4 ). A total of 61 subjects (44 ) met criteria for at least one lifetime diagnosis, namely mood disorder (27 , including 3 with bipolar disorder), anxiety disorder (11 ), substance use disorder (6 ), disruptive behaviour disorder (6 ) and ADHD (5 ). The Child Behavior Checklist (CBCL) 55 was used in these subjects and in controls from the general population, to assess behavioural and emotional problems, according to self-rating as well as parents' and teachers' evaluation. Higher scores were found for 8 of the 11 subscales of the self-administered CBCL (mostly concerning internalizing...


From a review of the relevant literature published during the past four years, it seems that the prevalence of ADHD ranges between 7 and 16 18-22 . This large range of percentages is probably the result of having examined different ages as well having employed different diagnostic tools. Moreover, the possibility of underdiagnosis or overdiagnosis should also be considered. A research study conducted in Israel 23 with adolescents who were at the initial stages of examinations prior to military service (thus, a healthy population sample) found a prevalence of ADHD of 4.9 . Thus, we are discussing a disorder that is prevalent among a population which is defined as healthy. In clinical studies, the diagnosis of ADHD is more frequent among males than females, with a ratio of 9 1, compared to only 4 1 in epidemiological studies. Part of the gap between boys and girls may be explained by the fact that the disorder is much more easily identified in boys, due to their marked hyperactivity,...

Mood Disorders

Mood disorders in children and adolescents are often severe and liable to cause significant morbidity and mortality 42,43 . For several years childhood depression was underdiagnosed, but today we are better able to identify and diagnose it in early childhood. Mania is undergoing the same process today. In certain cases, what was defined as ADHD or behaviour disorder turns out to be a ''covert mania''. In follow-up studies of ADHD and disruptive behaviours, a high frequency of mood disorders (including bipolar disorder) has been observed, which were diagnosed at a later stage in the child's life. Therefore, the greater our ability to refine the clinical criteria of mania in children and develop suitable scales, the better will we be able to identify maniform conditions at a younger age and differentiate them from ADHD and behaviour disorders. However, bipolar disorder, ADHD, disruptive behaviours and drug abuse are also likely to co-occur in the same subjects 44 . These subjects are...

Major Depression

In treating the child who is suffering from ADHD, it is important to remember that psychostimulants are liable to arouse a clinical depression which was previously covert. Depressive symptoms also play a prominent role in the clinic for children with CD ODD. On the other hand, a behaviour disorder may lead the child to recurrent social failures that in turn lead to damage of self-worth and subsequently to depression. Accordingly, depression is one of the main phenomena that must be examined and discounted in children exhibiting any kind of behaviour disorder. This demand is especially vital in light of the empathic failure that these children create, due to which internalizing disorders are not examined or diagnosed sufficiently 47 .

Bipolar Disorder

Epidemiological studies show that children and adolescents suffering from bipolar disorder almost always develop additional disorders 49 . These generally include CD, ODD and ADHD, as well as substance abuse and anxiety disorders. Several researchers are convinced that bipolar disorder appearing at a young age represents a more difficult and persistent form of the illness 50 . Suicidal ideation and attempts are at least as frequent in bipolar adolescents as in adults. A striking characteristic is the familial connection between ADHD, bipolar disorder and behavioural disorders, and the branching out at later stages of one diagnosis (bipolar disorder) from the earlier diagnoses (ADHD or behavioural disorder). This indicates the importance of bipolar disorder in relation to the difficult child, who is generally diagnosed initially as suffering from ADHD or behavioural disorder or from a combination of the two.

Organic Syndromes

An additional significant element is the high risk of comorbidity between ''difficult child'' syndromes and a secondary organic disorder due to physical injury. For example, children suffering from ADHD tend to bruise more easily, suffer from injuries demanding hospitalization and from head injuries and develop organic residua. In a study by DiScala et al. 62 , the characteristics of injuries suffered by ADHD children were compared to those of children not suffering from this disorder. It was found that children suffering from ADHD are more likely to be injured as pedestrians or cyclists and to suffer from self-inflicted injuries. In addition, they are more likely to suffer from multiple physical injuries, head injuries and more severe injuries. The time they spent in hospital was longer, and they were referred to the intensive care unit more frequently. In this study, 53 of the cases resulted in long-term injury or disability, as opposed to 48 in non-ADHD children. As a result, they...

Available Tests

And thromboembolic disease (Hille et al. Ridker et al. Simioni et al.), and the identification of the HFE gene for hereditary hemochromatosis (Beutler et al. Edwards et al.). In the second decade of the twenty-first century it has been predicted that genetic tests will be available for diabetes, asthma, dyslexia, attention deficit hyperactivity disorder, obesity, and schizophrenia. These discoveries point to the potential use of genetic tests for population screening in adult populations and an increasing role in public health for genetic testing.

Other Models

Finally, there is the view that it is a sense of self-efficacy and self-confidence that comes with successfully mastering one's brain wave activity that leads to increased self-regulation of behaviors. This, however, seems unlikely to be a major factor inasmuch as children with ADHD very often enjoy and master computer games with no obvious improvement in symptoms.

Bonnie Patterson MD

The definition of attention deficit hyperactivity disorder (ADHD) includes attention problems being present for at least 1 year occurring in more than one setting and behavior characterized by inattention, dis-tractibility, overactivity, and impulsivity. Attention problems are often reported in children with Down syndrome by parents or teachers but should be evaluated with the child's developmental age in mind rather than chrono logical age. The use of parent and teacher rating scales, such as the Conner's Rating Scale or the Achenbach Child Behavior Checklist, can aid in making the diagnosis. (The scales used must be appropriate for the child's developmental level.) If children with Down syndrome are diagnosed with ADHD, the interventions are the same as those for children of a similar developmental age without Down syndrome. Behavioral strategies will need to be instituted both at home and at school, and if a psychostimulant medication, such as Ritalin or Adderall, is prescribed it...


Participants in a majority of the studies conducted with the GBG have consisted primarily of elementary-age students (first through sixth grades). Also, although not always specified, most studies have been conducted either with regular education students or students who have had some history of behavior management difficulties. Only a few investigations of the GBG have been conducted with students with disabilities. One study employed a modified version of the game to effectively reduce class levels of disruptive behavior with 6- to 10-year-old students with mild mental retardation. Another study that combined self-management and peer-monitoring procedures in a variation of the GBG successfully reduced uncontrolled verbalizations in third-grade students with Attention Deficit Hyperactivity Disorder. Researchers have also individualized the GBG across types and frequencies of a variety of inappropriate behaviors for three classes of 15- to 17-year-old students with emotional...

Tourettes Syndrome

Some psychiatric disorders, like Tourette's syndrome, have significant overlap (co-morbidity) with other psychiatric disorders (OCD and ADHD in the case of Tourette's). This may make the elucidation of genetic causes more difficult. Tourette's syndrome is characterized by multiple motor tics and one or more vocal tics. It has onset before eighteen years and is one and one-half to three times more common in males. Twin, adoption, and segregation analysis studies support a genetic etiology for Tourette's syndrome. An autosomal dominant inheritance was initially suggested, but other inheritance patterns have been recently reported. There appears to be a relation with ADHD (up to 50 percent of individuals with Tourette's also have ADHD) and OCD (up to 40 percent of individuals with Tourette's have OCD). First-degree relatives are at high risk for developing tics and obsessive compulsive disorders.

Highrisk Studies

Attentional difficulties have been of interest to high-risk researchers and consistently emerge as a possible neurobehavioural marker in such studies. In the New York High-risk Project, more than a quarter of high-risk children showed problems with attention by age 7 and these difficulties persisted into adolescence and adulthood 42 . Attention deficits measured at the onset of adolescence yielded approximately 78 correct classification of future schizophrenia spectrum disorders, with a sensitivity of 67 and a specificity of 79 43 . This is considerably better than the prediction afforded by looking at genetic vulnerability alone. While attentional deficits appear to be a promising indicator, Cornblatt et al. 43 urge caution and note that the specificity of this predictor has not yet been demonstrated in studies comparing adolescents with attention deficit disorder versus those with a schizophrenic parent.

William M Klykylo

Other reports have suggested an increased level of comorbidity for substance abuse among adolescents and young adults with attention deficit hyperactivity disorder. This may be particularly marked among patients with associated learning problems, family dysfunction, or social economic distress. Researchers have speculated as to whether this might result from an underlying biobehavioral predisposition, the consequence of an impulsive lifestyle and social and educational failures, or various other combinations of factors. The most commonly diagnosed psychiatric disorder in children in the United States is attention deficit hyperactivity disorder (ADHD). Various rates of prevalence from 3 to 10 have been reported. The recognition of this disorder is influenced by many external factors, such as particular family, social, and educational expectations and the availability of mental health services. It is said that this condition is both heavily underdiagnosed and overdiagnosed. It is also...

Clinical Picture

The three components that constitute the basis for the diagnosis of ADHD, both at school age and earlier, are inattention, impulsiveness and hyper-activity. Nevertheless, levels of activity and attention in infancy are totally different from those at the kindergarten or school stage. In most cases, a suspicion of ADHD is not raised before the age of 2 years. When a 1-year-old baby is very active, does not sleep very much during the day, wakes up frequently at night, does not have regular biological rhythms and does not play on his her own, the tendency is to diagnose a difficult character, in other words, a variation within the norm, and not ADHD, which is a deviation from the norm. When there is in addition a disturbance in senso-motor regulation, a diagnosis of regulation disorder will usually be made 26 . In a longitudinal research study from birth until the age of 7 years, Palfrey et al. 27 found that only 3 of parents of infants up to the age of 14 months expressed concern...

Andrea M Chronis

Keywords ADHD, parent training, behavior problems, oppositional defiant disorder, conduct disorder Behavioral parent training has been established as an empirically supported treatment for attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). Parent training programs focus on teaching parents behavior modification techniques based on social learning principles. Parents are instructed to modify antecedents and consequences of child misbehavior by rewarding prosocial behavior through contingent praise, positive attention, and rewards, and extinguishing maladap-tive behavior through ignoring, response cost, and discipline techniques such as time-out. For parent training to be maximally effective, parents must implement these techniques consistently. Although there is some evidence to suggest that participation in parent training may improve parent stress, parenting self-esteem, and marital adjustment, parent functioning is...


Blair I want to return to the delay of gratification and impulse control questions. The disadvantage of having this as the link between empathy and prosocial behaviour is that one of the measures was the emotional response to the pictures. This index of the basic emotional response is unlikely to relate to delay of gratification in the way that it is usually thought about. It would be difficult to link these two. Regarding the impulse control, we can be pretty sure that impulse control more generally is not the thing that is driving empathy because you have children with attention deficit hyperactivity disorder (ADHD), a classic impulse control disorder, and they are not showing indications of profound empathy impairment. We can be confident that this is not the explanation.

Down Syndrome

The accepted stereotype of persons with DS is that they are happy, social, and friendly however, this is not scientifically based. Instead, studies have shown that children with DS have temperament profiles that are comparable to those of typically developing children. Children with DS have difficulty in the area of social competence, perhaps due to concomitant motor, cognitive, and language delays. Individuals with DS exhibit other comorbid disorders, including attention deficit hyperactivity disorder, conduct op-positional disorder, aggression, phobias, stereotypic behavior and self-injurious behaviors.


Attention Deficit Hyperactivity Disorder Attention deficit hyperactivity disorder (ADHD) is a childhood psychiatric disorder characterized by inattention, impulsivity, and overactivity. Children with ADHD have difficulty completing tasks, they make careless mistakes, do not listen, lose things, and avoid tasks that require concentration, and they are forgetful and disorganized. The behavioral deficits ADHD are estimated to be present in 3-5 of all school-aged children and are believed to arise in early childhood. The neurotransmitter systems most commonly implicated in the pathophysiology of ADHD are the catecholamines, dopamine and NE. Virtually all medications that are effective in the treatment of ADHD, in particular psychostimulants such as me-thylphenidate, affect catecholamine transmission, and medications that do not interact with catecholamine transmission are rarely effective in the treatment of ADHD, thus indicating the possibility of a biological etiology. A relatively...


Benzodiazepines provide anxiolysis and amnesia but not anesthesia. They can be used alone as a sedative, or in conjunction with a narcotic or local anesthetic for a painful procedure. Midazolam (Versed) is a short-acting benzodiazepine that has an onset of action within 5 min and a duration of action of 30 to 45 min. Midazolam is safe and effective for use in the ED in children undergoing laceration repair, fracture reduction, and other painful procedures. 10 Adverse effects include respiratory depression and paradoxical inconsolability.11 Anecdotally, this latter effect appears to happen with increased frequency in children with attention deficit hyperactivity disorder, and is reversible with flumazenil.

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Has Your Child Been Diagnosed With ADHD Is Coping With Your Child's Behavior Wearing You Out Are You Tired of Searching For Answers An ADHD child does not have to have a dark cloud over his or her head. If You've Got Burning Questions About ADHD, I've Got Answers.

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